I am interested in this documentation discussion. When I was designing my new forms I talked to many people within the OT and PT crowd. The overwhelming idea among PTs was that OTs tend to be too wordy. "Being wordy" equated with an increased chance of a reviewer finding some little section within our ramblings that they could use as a reason to deny a claim. (I used the word "ramblings"...NOT the PTs.) I see this as a very valid point.
On the other hand, our type of therapy is more complex (encompasses many more aspects of a person's life) and by its nature requires more words to describe. We are involved in quality of life and all the nuances that bring that quality to our clients. I can read 2 PT reports on 2 different patients and they will use identical words. Most of the time, the PT performed exactly the same exercise routine. And that is absolutely appropriate for physical therapy. I have rarely written 2 reports that are identical. I admit that I tend to be "wordy" but I use my notes to guide my next session. When I am in a hurry and quickly write a note with only the required parts of the note, I look back the next week and beat myself up because I don't have enough information to truly get a picture of what was accomplished and where I planned to go next. I work in low vision rehabilitation right now and one of my mentors told me that often the largest change from evaluation to discharge is reflected in the patient's perception of their life with vision loss. We teach clients all of these skills and how to compensate, but at the end, it is their ability to adapt to their current life situation and their satisfaction with their abilities that determine success or failure. I feel the need to be "wordy" on my documentation...can you tell that in my rambling here? Jenny Daup -- Options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected] ************************************************************************************** Enroll in Boston University's post-professional Master of Science for OTs Online. Gain the skills and credentials to propel your career. www.otdegree.com/otn **************************************************************************************
